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| Section | Weight | Objectives |
|---|---|---|
| Surgery Coding | 40-50% | - Nervous System - Respiratory System - Digestive System - Musculoskeletal System - Cardiovascular System - Genitourinary System - Integumentary System |
| E/M (Evaluation and Management) | 10-15% | - Emergency Department - Office/Outpatient Visits |
| Medicine | 5-10% | - Specialty Coding |
| HCPCS Level II | 5-10% | - Modifiers - Supplies and Equipment |
| ICD-10-CM (Diagnosis Coding) | 10-15% | - Code Selection - Conventions and Guidelines |
| Anatomy & Physiology | 10-15% | - Body Systems - Medical Terminology |
| Laboratory / Pathology | 5-10% | - Organ and Disease Panels |
| Radiology | 5-10% | - Diagnostic Imaging |
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NEW QUESTION # 109
(A provider states that all of their office visits should be reported asmoderate levelsbecause they treat patients with high-complexity problems. Would this be considered a compliance problem?)
Answer: A
Explanation:
Systematically billing all office visits at a predetermined level-without documentation supporting the requiredmedical decision making (MDM)ortime-is a classic compliance red flag and is generally treated asabuse(often described as upcoding when higher levels are billed than supported). E/M levels must reflect what was actually performed and documented for that encounter, using the E/M rules (MDM elements or total time, depending on code selection). Even if a provider treats complex patients, not every visit will meet the same level; stable follow-ups may be lower complexity than acute exacerbations or new problems. "Waste" generally refers to inefficient or unnecessary use of resources without intent to misrepresent; a blanket instruction to code moderate levels suggestssystematic misbillingrather than inefficiency. Option D is incorrect because providers cannot select any level at will-coding must be supported by documentation. This type of pattern is exactly what audits target, and it can trigger overpayment recoupment, penalties, and corrective action plans.
NEW QUESTION # 110
(Full Case:Patient:V. Bowen.Physician:C.S., MD.Reason for admission:Abdominal pain.HPI:admitted this morning; sudden onset RUQ pain began ~4:00 p.m. yesterday; started while eating; 8/10; chills/sweating
/nausea; no vomiting/diarrhea; last BM 2:00 p.m. yesterday; unable to pass stool or gas since; abdominal distention; poor sleep; prior similar episodes relieved by gas tablets but not this time; no discolored stool/urine.
PMH:HTN (losartan; missed dose).PSH:bunion surgery right foot.FH:HTN.SH:no smoking/alcohol.Meds:
losartan daily.Allergies:NKDA.ROS:nausea, no emesis; no flatus/stool since yesterday; no weight change; no SOB/chest pain; no jaundice; no urinary frequency/urgency.PE:alert/oriented x3; obvious abdominal discomfort. Vitals 139/100, pulse 100, RR 16, temp 36.4. HEENT normal; CV regular; lungs clear. Abdomen:
+BS, soft but very tender; worst RUQ;Murphy's sign; guarding and rebound (worse with palpation).
Extremities trace edema.Labs ordered/reviewed:CMP with abnormal LFT/bili; CBC WBC 9.9; etc.Final assessment:RUQ abdominal pain,rule out cholecystitis.Plan:NPO; morphine IV (controlled substance); IV NS
150 cc/hr; abdominal ultrasound and HIDA ordered; consider surgical consult based on results.Question:What CPT and ICD-10-CM codes are reported?)
Answer: A
Explanation:
This is aninitial hospital service(admitted this morning; "reason for admission"), so the correct E/M family isinitial hospital inpatient/observation carerather than subsequent hospital care (99232/99233). The encounter includes a detailed history, comprehensive exam elements focused on abdominal pathology, and meaningful initial management: NPO, IV fluids,IV morphine, ordering and reviewing lab panels, and ordering imaging (ultrasound and HIDA) with possible surgical consultation-supporting at leastmoderate MDM, consistent with99222in typical CPC exam mapping. Diagnosis coding: "rule out cholecystitis" is not a confirmed inpatient discharge diagnosis in the provided note; at this stage the physician's final assessment isRUQ abdominal pain, rule out cholecystitis. Therefore, you report thesign/symptomcodeR10.11 (right upper quadrant pain)rather thanK81.9(cholecystitis, unspecified), because cholecystitis is not established as definitive in the note. Option A correctly pairs an initial hospital E/M code with the symptom diagnosis supported by documentation.
NEW QUESTION # 111
A 32-year-old is in the outpatient clinic for an esophagoscopy due to increased difficulty swallowing with his eosinophilic esophagitis. The flexible scope is inserted in the mouth and into the esophagus. Examination of the esophagus noted narrowing in the distal esophagus. Following an injection of Kenalog, a transendoscopic balloon dilation was performed in the area of stenosis. Inflation was repeated eventually reaching 18 mm in diameter. What CPTcoding is reported for this procedure?
Answer: D
NEW QUESTION # 112
View MR 002395
MR 002395
Operative Report
Pre-operative Diagnosis: Acute rotator cuff tear
Post-operative Diagnosis: Acute rotator cuff tear, synovitis
Procedures:
1) Rotator cuff repair
2) Biceps Tenodesis
3) Claviculectomy
4) Coracoacromial ligament release
Indication: Rotator cuff injury of a 32-year-old male, sustained while playing soccer.
Findings: Complete tear of the right rotator cuff, synovitis, impingement.
Procedure: The patient was prepared for surgery and placed in left lateral decubitus position. Standard posterior arthroscopy portals were made followed by an anterior-superior portal. Diagnostic arthroscopy was performed. Significant synovitis was carefully debrided. There was a full-thickness upper 3rd subscapularis tear, which was repaired. The lesser tuberosity was debrided back to bleeding healthy bone and a Mitek 4.5 mm helix anchor was placed in the lesser tuberosity. Sutures were passed through the subcapulans in a combination of horizontal mattress and simple interrupted fashion and then tied. There was a partial-thickness tearing of the long head of the biceps. The biceps were released and then anchored in the intertubercular groove with a screw. There was a large anterior acromial spur with subacromial impingement. A CA ligament was released and acromioplasty was performed. Attention was then directed to the supraspinatus tendon tear. The tear was V-shaped and measured approximately 2.5 cm from anterior to posterior. Two Smith & Nephew PEEK anchors were used for the medial row utilizing Healicoil anchors. Side-to-side stitches were placed. One set of suture tape from each of the medial anchors was then placed through a laterally placed Mitek helix PEEK knotless anchor which was fully inserted after tensioning the tapes. A solid repair was obtained. Next there were severe degenerative changes at the AC joint of approximately 8 to 10 mm. The distal clavicle was resected taking care to preserve the superior AC joint capsule. The shoulder was thoroughly lavaged. The instruments were removed and the incisions were closed in routine fashion. Sterile dressing was applied. The patient was transferred to recovery in stable condition.
What CPT coding is reported for this case?
Answer: D
Explanation:
29827: Arthroscopic rotator cuff repair is correctly coded as 29827.
29828: Arthroscopic biceps tenodesis is an additional procedure and should be coded as 29828 with modifier -51 (Multiple Procedures).
29824: Arthroscopic claviculectomy (partial resection of the distal clavicle) is coded as 29824 with modifier -51.
29826: Arthroscopic subacromial decompression, including coracoacromial ligament release, is coded as 29826.
All these procedures were performed arthroscopically and documented in the operative report, justifying the use of these codes and the use of modifier -51 for multiple procedures.
CPT Professional Edition, AMA
NEW QUESTION # 113
A patient suffers a ruptured infrarenal abdominal aortic aneurysm requiring emergent endovascular repair. An aorto-aortic tube endograft is positioned in the aorta and a balloon dilation is performed at the proximal and distal seal zones of the endograft. The balloon angioplasty is performed for endoleak treatment.
What CPT code does the vascular surgeon use to report the procedure?
Answer: D
Explanation:
The emergent endovascular repair of an infrarenal abdominal aortic aneurysm with an aorto-aortic tube endograft is coded with CPT 34702. This code includes the deployment of the endograft and the necessary balloon angioplasty for sealing the proximal and distal attachment zones.
Reference:
AMA's CPT Professional Edition (current year)
NEW QUESTION # 114
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